Richland Hills Rehabilitation and Healthcare Cente

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for 1 of 5 residents (Resident #22) reviewed for accidents. The facility failed to ensure Resident #22's non-slip mat was placed in his wheelchair for fall prevention. This failure could place residents at risk of falls and injury.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe, clean, comfortable environment, including but not limited to receiving treatments and support for daily living for 6 of 11 residents (Resident #2, Resident #7, Resident #16, Resident #48, Resident #56 and Resident #60) reviewed for safe, clean and comfortable environment. 1. The facility failed to ensure Residents #16 and #7's privacy curtain was clean and free of stains on 05/05/26. 2. The facility failed to ensure Resident #48 and Resident #60 had clean, stain-free sheets and bedding on 5/6/26. 3. The facility failed to ensure Resident #56 had clean stain-free sheets on 5/5/26 and 5/6/26. 4. The facility failed to ensure Resident #48 had good draining sink in his restroom. 5. The facility failed to ensure Resident #2 had a floor base board on the wall under her bed near the window. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 kitchen reviewed for food service safety for the facility's only kitchen. 1. The facility failed to ensure the oven and stove top were free of blackened sticky residue and stove top had working burners on 05/05/26. 2. The facility failed to ensure Dietary Manager and Dietary Aide J used proper hand hygiene during lunch meal preparation on 05/06/26. 3. The facility failed to ensure Dietary Aide J wore effective hair restraints to cover about a foot of her hair in the back during lunch meal preparation on 05/06/26. 4. The facility failed to ensure Dietary Aides K wore effective facial hair restraint to cover his mustache during lunch meal preparation on 05/06/26. 5. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 residents (Resident #2 and Resident #28) of 5 residents reviewed for ADLs. The facility failed to ensure:Resident #2 had her fingernails trimmed and cleaned on both hands on 05/06/2026. Resident #28 had his fingernails trimmed and cleaned on both hands on 05/06/2026. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and skin breakdown, and a decreased quality of life.1-Resident #2Record Review of Resident #2's Quarterly MDS assessment dated [DATE] revealed a [AGE] year-old female with initial admission date of 07/22/2019. Her pertinent diagnoses included: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to assist residents in obtaining routine and 24-hour emergency dental care for 1 of 8 residents (Resident #58) reviewed for dental services. The facility failed to refer Resident #58 for dental services after he was admitted to the facility on [DATE] despite having visibly decayed and broken teeth. This failure could affect the residents' comfort, dignity and their nutritional statusA record review of Resident #58's Face Sheet dated 5/7/26 reflected an [AGE] year-old male admitted to the facility on [DATE]. Resident #58 had the following pertinent diagnoses: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 2 residents (Resident #68 and Resident #54) of 4 reviewed for infection control. 1. The facility failed to ensure MA G changed gloves and completed hand hygiene during incontinent care for Resident #68 on 5/5/26. 2. The facility failed to ensure Resident #54's mattress was free of brownish material and stains on 05/05/26. These failures could place residents at risk for infection and cross contamination of pathogens and illness.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 resident (Resident #1) reviewed for transfers with assistive devices. The facility failed to ensure staff followed Resident #1's care plan and safe transfer procedures. The facility failed to ensure CNA B used a mechanical lift with assistance from another staff person to transfer Resident #1 on 10/24/25. This failure placed residents at risk of falling, injuries and a decline in health.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure all drugs and biologicals were securely stored for 2 of 2 medication carts (Medication Cart A and B) reviewed for storage of drugs and biologicals. The facility failed to ensure medication carts A and B were locked and secured. On 10/24/25 MA A left medication cart A unlocked and unsecured. On 10/27/25 MA D left medication cart B unlocked and unsecured. This failure could place residents at risk of medication misuse or drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep and store confidential information as required, except when requested by an approved place or person for 1 of 1 resident (Resident #2) reviewed for unsecured confidential information on top of medication cart. The facility failed to ensure resident specific medication materials were secured for Resident #2 on 10/24/25. This failure had the potential to expose sensitive information to unauthorized individuals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for two residents (Resident #2 and Resident #3) of three residents reviewed for infection control. The facility failed to ensure Resident #2, who was on enhanced barrier precautions for Candidiasis (yeast infection), unspecified, received Tracheostomy care via sterile technique. The facility failed to ensure Resident #3, who was on enhanced barrier precautions for osteomyelitis (infection of bone caused by bacteria) and sacral (base of the spine) pressure ulcer received wound care using aseptic (free from microorganisms) technique. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the menu was followed for one of one meal (lunch on 02/26/2025) reviewed for food and nutrition services. The facility failed to ensure the menu was followed for the lunch meal by leaving out the dinner roll with margarine for all diet types on 02/26/2025. This deficient practice could place residents at risk of dissatisfaction, poor intake, and/or weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare foods according to the established food preparation practices and safety techniques in 1 of 1 kitchen reviewed for appropriate sanitation, as evidenced by: The warewasher (dish machine) sanitizer was not dispensing sanitizer, leaving the dishes used for the afternoon meal, of 02/24/25 through afternoon meal of 02/26/25, unsanitized. This failure could place residents at risk of infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents with wounds receives necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection for 3 of 3 residents (Residents #25, #30 and #107) reviewed for wound care. 1. The facility failed to ensure Resident #25 and Resident #107 received wound care everyday as per physician orders on 02/25/25. 2. LVN A failed to update physician wound care orders in the MAR when Resident #30 was seen by the Wound Care Physician on 02/17/25. These failures placed residents at risk for infection and delay in healing of existing wounds.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards for 2 of 2 residents (Residents #56 and #107) reviewed for intravenous fluids. The facility failed to ensure Resident #56 and Resident #107 Midline/PICC line (used to deliver medications and other treatments directly to the large central veins near heart) dressing change was completed and the change date was documented on the dressing. Resident #56 and Resident #107 were observed without change dates and initials on 02/24/25. The failures could affect residents by placing them at risk for infections and cross-contamination due to not knowing when the dressing was last changed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored securely for 2 of 2 residents (Resident #15 and Resident #40) reviewed for medication storage. 1. The facility failed to ensure Resident #40's 1 bottle of nitroglycerin 0.4 mg was stored in a secured place when they were stored in her room on her bed side table on 02/24/25. 2. The facility failed to ensure Resident #15's 1 bottle of 100 mg/Stool Softener with stimulant, 2 bottles of Clear Eyes .5 ounces each, 1 bottle of 190 heartburn relief tablets, 100 capsules allergy relief 25 mg, 1 bottle of Linzess prescription with the label peeled for whom it was prescribed to, and 1 bottle of acetaminophen 325 mg was not stored at the resident's bedside table. [...]

Inspectors wroteBased on interview and record review, the facility failed to permit the resident to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility for 1 of 2 residents (Resident #199) reviewed for facility-initiated discharges. The facility failed to permit Resident #199 to remain in the facility and discharged the resident from the facility. Resident #199 was not allowed to return to the facility following a neurologist's appointment on 12/18/24 due to the facility having the resident sign an AMA form before she left for the appointment. After refusing Resident #199 to enter back into the facility, the facility called EMS who took her to a hospital for an evaluation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing program of in-room activities in accordance with the comprehensive assessment to meet the interests and the physical, mental, and psychosocial well-being of 1 of 18 (Resident #46) residents reviewed for activities. The facility did not provide Resident #46 ongoing individualized in-room activities for a minimum of fifteen minutes three times per week for the period between 02/25/25 to 02/27/25. This failure could place residents who required in room activities at risk for not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for 1 of 5 residents (Resident #9) reviewed for restorative care. The facility failed to apply splint to Resident #9's left hand to reduce the risk of further loss of range of motion on 02/25/25 and 02/26/25. This failure placed ten residents on with devices for contractures at risk for decline in range of motion, decreased mobility, and worsening of contractures.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 2 of 2 residents (Residents #25 and #107) reviewed for wound care administration. 1. The facility failed to ensure staff accurately documented on Resident #25 and #107's MAR/TAR after performing wound care on 02/26/25. This failure could put residents at risk for treatment errors and errors in care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 resident (Resident #31) reviewed for infection control. The facility failed to ensure LVN B put on a gown before providing g-tube medication to Resident #31, who was on Enhanced Barrier Precautions. This failure could place residents at risk of contracting an infection from residents on Enhanced Barrier Precautions and cross contamination, which could result in infections or illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a centralized staff work area, for 1 of 54 residents (Resident #29) reviewed for call lights. The facility did not adequately equip Resident #29 with a call light to allow the resident to call for assistance. This failure could place residents who rely on the call light system to have a delayed response or no way to contact staff to meet their needs.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, which includes but not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms for 1 (Resident #1) of 3 residents reviewed for involuntary seclusion. The facility failed to ensure the ADON did not tip Resident #1's wheelchair forward, dump him onto his bed, remove his wheelchair from the room, and close the resident's door. This failure could place residents at risk of injury, falls from bed, and decreased sense of self worth.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident was treated with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for two of eight residents (Residents #3 and #4) reviewed for dignity. 1. The facility failed to ensure the urinary collection bag for Resident #3's catheter was covered with a privacy bag. 2. The facility failed to ensure the urinary collection bag for Resident #4's catheter was covered with a privacy bag. These failures could place residents at risk for a loss of dignity, decreased self-worth and decreased self-esteem.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the residents had the right to personal privacy and confidentiality of his or her personal space for two of eight residents (Residents #1 and #2) reviewed for privacy. The facility failed to ensure there was a privacy curtain in Resident's #1 and #2's room since Resident #2's admission to the facility on [DATE]. This failure could place residents at risk for a loss of privacy, dignity, and decreased self-worth and self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to ensure care plans were developed in consultation with the resident and the resident's representative for 3 of 13 residents (Resident #3, Resident #7, Resident #17) reviewed for Comprehensive Care Plan in that: The facility failed to ensure Resident #3, Resident #7, and Resident #17 or the resident's representatives were invited to participate in the residents' care plan meeting. This failure could place residents at risk for a loss of independence, psychosocial well-being, and the opportunity for them to participate in the planning of their cares.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident resided and received services in the facility with reasonable accommodation of resident needs and preferences for 3 (Resident #3, Resident #7, and Resident #27) of 13 residents reviewed for call lights. Staff failed to ensure Resident #3 and Resident #7's, and Resident #27's call buttons were within reach. This failure could place residents at risk for decreased quality of life, self-worth, and dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was not 5 percent (5%) or greater for 3 of 25 opportunities resulting in a 8 percent medication error rate for 1 of 10 residents observed for medication pass. Facility failed to ensure Resident #6 medications were administered as physician order. Facility failed to ensure Resident #6 medication were not crushed or mixed into a cocktailed without a physician order. Facility failed to ensure Resident #6 received chewable aspirin instead of safety coated aspirin that was crushed without a physician order. These failures could place residents at risk for significant medication errors and jeopardize the resident health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 6 (Residents #6, #39, #42, #43, #49, and #204) of 10 residents reviewed for infection control. The facility failed to implement an infection control and prevention that included wound care procedures and cross contamination for Resident #39 and #43 during wound care. The facility failed to ensure CMA C sanitized blood pressure cuff between use on Residents #6, #42, #49, and #204. The facility failed to ensure CNA F maintained a contaminate free clean linen for all residents in BACK HALL ODD and BACK HALL EVEN hallway from rooms 21 to room [ROOM NUMBER]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure clean, comfortable environment and maintenance services for one esident #30) of eight residents reviewed for clean and comfortable environment. The facility failed to maintain functional plumbing in the bathroom of Resident #30, causing her sink to not drain properly, to the extent she could not get hot water in her bathroom sink. These failures could place residents at risk for lack of hygiene, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who received nutrition by enteral means received the appropriate treatment and services according to professional standards of maintenance for one (Resident #40) of one resident reviewed for enteral feeding. The facility failed to ensure Resident #40's g-tube water and enteral administration set (tubing attached to formula and water bottles for continuous g-tube feeding) was changed when his formula was changed, and failed to ensure the formula was dated when it was changed. This failure could place residents at risk of infection due to not following appropriate procedures.

Inspectors wroteBased on observation, interview, and record review, facility failed to provide necessary respiratory care consistent with professional standards of practice, for 1 (Resident # 22) of 4 residents reviewed for Oxygen therapy. Facility failed to ensure Resident #22 had a portable oxygen tank that was not depleted of consistent oxygen therapy. This failure could place resident at risk for difficulty breathing, anxiety, shortness of breath.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals used in the facility are labeled in accordance with professional standards, including expiration dates and with appropriate accessory and cautionary instructions for 1 (Resident #15) of 10 residents reviewed for storage of drugs and Biologicals. Facility failed to ensure insulin for Resident #15 was correctly labeled with the date it was opened.

Inspectors wroteBased on interview and record review, the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS for 1 of 4 quarters reviewed for Fiscal year Quarter four of 2023 (July 1- September 30). The facility failed to submit RN staff hours for 07/15/23, 08/11/23, 08/18/23, 08/19/23, 08/25/23, 08/26/23, 09/02/23, 09/09/23, 09/16/23, and 09/23/23. The facility's failures could place residents at risk for needs not being met and a decreased quality of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision and assistive devices to prevent accidents for one (Resident #1) of three residents reviewed for accidents. CNA B failed to have assistance from another staff member when she transferred Resident #1, who required 2-person assist with transfers, via a mechanical lift resulting in Resident #1 sustaining a shoulder fracture. This failure placed residents at risk for accidents and injuries.